When Things Happen – The Story of COVID-19, Palliative Care, and An NGO

Abstract

Several natural disasters and the appearance of the coronavirus disease 2019 (COVID-19) pandemic created stressful situations to many health-care workers in the Philippines. New health-related challenges surfaced, and health-care workers felt lost since many of the challenges were either directly or indirectly caused by the fast-spreading coronavirus infections and its variants. Further, the way people die also changed, causing confusion and influencing the Filipino grief and bereavement processes. In response to the need of the health-care workers, a nongovernmental organization (NGO) through its education portal created and offered free webinars, aimed to help health-care workers understand and make sense of what was happening, thus empowering them with knowledge on how to manage the challenges and provide better care to the patients and the community as well. This article relates the process of planning and implementing online webinars during the era of social distancing and COVID-19 pandemic.

Introduction

Globally, 2020 turned out to be a very difficult year. For many Filipinos, 2020 is especially challenging since they have not only endured the pandemic crisis but several natural disasters as well. Early in the year, the eruption of Taal Volcano disrupted much of the daily activities in the major city of Manila and many of its neighboring provinces in Southern Luzon.[1] Even before the people could adequately recover, the country reported its very first case of the coronavirus disease 2019 (COVID-19) infection, brought in by two vacationing tourists from China.[2] The two patients followed different trajectories and demonstrated different severity of the disease, causing an alarm that the novel coronavirus had varied characteristics, still unknown at that time. As the infection became more widespread, with community lockdowns and quarantine requirements, the demands on the country's health-care system were more palpable than ever. The burden created by COVID-19 was further magnified by shortages of hospital beds, limited manpower and other essential supplies, increasing mortality rates, coupled with the social stigma and economic impact of the disease. Mid-year, through the rainy season, the country was again devastated by severe weather conditions and heavy typhoons that further placed the country's resources in jeopardy. Many Filipinos died with unnatural and untimely deaths, affecting not only the families but the health-care workers as well. The unexpected losses potentially compromised the coping capacities of many.

Realizing that patients, families and frontliners were highly at risk, a non-governmental non-profit foundation: The Ruth Foundation (TRF) responded through its Hospice Opportunity for Patient Empowerment (HOPE) program by offering free online education to health-care workers. The overall goal of the project was to support health-care workers who deal with the COVID-19 pandemic and armed with the knowledge, they can, in turn, support the patients and families who are under their care.

Based in Metro Manila, Philippines, TRF's primary purpose is providing community-based opportunities for service in the care of the home-bound elderly and those with life-limiting illness. Together with the service component, TRF also has the HOPE program which aims to educate and train nurses, volunteers/caregivers, and other community-based health professionals so they can, in turn, empower their patients and families in palliative and hospice care.[3] In its provision of palliative and hospice care education, TRF partners with the US-based End-of-Life Nursing Education Consortium (ELNEC), a long-time and well-established project between the American Association of Colleges of Nursing and the City of Hope Medical Center.

In the era of the COVID-19 pandemic, ELNEC created an online resource for nurses to equip them in dealing with COVID-19 patients and their families. The on-line project is called ELNEC Support for Nurses During COVID-19 and is available for free.[4] The site contained recorded video presentations of ELNEC Core Modules including slides that were adapted to fit the needs and requirements in caring for patients and families with COVID-19. It also contains free infographics and video vignettes to support nurses who are frontliners so they can effectively navigate the many unknowns of caring for COVID-19 patients and their families.

Process

Realizing that there was a need for education, the TRF training team requested and was granted permission to use the ELNEC-COVID-19 project in hosting an educational webinar related to pandemic and palliative care. An electronic survey asking for interest in the program, possible logistical processes (most feasible time, length of program, and others), and current experience in caring for COVID-19 patients and families were sent to a selected group of health-care providers. Results were overwhelmingly positive for the need of such a program with an echoing interest to learn more about the COVID-19 infections, its symptoms and management, and a futuristic look at what the world would be like after the pandemic. Content discussions with the in-house experts resulted in a webinar that would cover the current state of the COVID-19 infections, how it relates to palliative care with an overall theme of embracing the needs of the health-care providers as they relate and care for the COVID-19 patients and their families.

The training team reviewed the content in the ELNEC COVID-19 project and chose the content that would be applicable to the webinars. Three of the ELNEC COVID-19 videos were chosen and five additional lectures were developed by the foundation experts based on the identified needs from the survey, and to complete the spectrum of what is required when caring for COVID-19 patients and their families. Ethical considerations were added since COVID-19 brought many related ethical concerns and for many Filipinos, ethics are most commonly based on the beliefs and traditions of the family. The TRF experts thought that having a lecture/discussion on ethics would help health-care workers manage the often unclear and controversial issues related to COVID-19 care in particular and palliative care in general. All the materials were adapted and contextualized according to the culture, beliefs, and ways of the Filipino people. Table 1 shows the eight topics contained in the TRF-ELNEC COVID-19 webinar project. The three-video presentation from the ELNEC COVID-19 project was followed by a series of discussion points to further enhance and localize the content.

Table 1.

Lectures – TRF palliative care/COVID-19 webinar series

Title	Description
COVID-19 and palliative/supportive care	Content includes current evidence related to the COVID-19 infections and the role of palliative/supportive care during the COVID pandemic
Symptom management	Content includes basic principles of infection containment and currently known symptoms and management strategies of COVID-19
Ethical considerations	Adapted from ELNEC Critical Care Course Lecture on Ethics, content emphasizes the issues brought about by the pandemic including participation in COVID-19 clinical trials and advanced directives
Psychosocial care	Content includes common reactions to COVID-19 infections such as strict isolation/absence of family members, unpredictability of the course of the infection, and lack of control. Also, discusses various local resources available for frontliners to help cope with the demands of caring for COVID-19 patients and families
Last hours**	Content includes supporting a patient who may be dying alone, family care, breaking the news about patient’s death, postmortem care, and institutional/governmental requirements
Loss, grief, and bereavement**	Content deals with the impact of sudden/unexpected and cumulative deaths due to COVID-19 infections on patients, families, and health-care workers
Post-COVID-19 “The New Normal”	Content includes potential societal impact and changes that may happen after the pandemic such as in economics, travel, and social behaviors. Also, discusses the role of health-care workers in developing national and local government policies to prepare for the new normal
Self-care**	Content discusses the need to be “selfish” and care for self; also includes the perks provided by the government and private entities to show appreciation for the frontliners (free tollway passes, food deliveries, and others)

**ELNEC COVID resources videos. https://www.aacnnursing.org/ELNEC/COVID-19. ELNEC: End-of-Life Nursing Education Consortium; TRF: The Ruth Foundation ; COVID-19: coronavirus disease 2019

Entitled “TRF-ELNEC COVID-19 Webinar Series,” the program has been implemented twice, initially with Metro Manila participants (mostly the survey respondents), and the second program was offered for health-care workers in the different Visayan Islands.[5] The participants were all recruited through an invitational letter sent individually to them or through the medical and/or nursing directors of area hospitals. The free webinar offering was also advertised in the Foundations' Facebook page. Table 2 shows the demographics of the participants from the first and second offerings.

Table 2.

Demographics of webinar 1 and 2 participants

Category	Webinar series 1	Webinar series 2
RN	33	47
Physicians	33	19
Social workers	1	0
Others (PT), CHW, midwives	0 PT	0 PT
	0 CHW/Midwives	3 CHW/ Midwives

PT: Physical therapists; CHWs: Community Health Workers; RN: Registered Nurse

The Zoom platform (www.zoom.us) was used to conduct the webinars and proved to be very helpful in tracking the attendance of each participant in both groups. The Chat function of the Zoom platform allowed live discussions and exchange of ideas among participants and faculty. A certificate of attendance was given for each webinar attended and a certificate of completion was given to participants who attended all of the webinars.

The first program was offered on Mondays and Thursdays (12:00 N to 1:00 PM live and recorded for replay at 8:00–9:00 PM) for 4 weeks from June to July 2020. The format was lecture/discussion and using the Zoom Chat function, questions were raised with discussion and answers following. Being the first time the Foundation has done a webinar series, the training team considered it to be a learning curve on which to base future offerings in this type of format. Although comments and program evaluations were generally favorable, the training and the faculty group decided to revise program delivery for the second offering. The revisions were based on faculty scheduling, participant's comments, and time availability. Further, project staff used many hours in processing needed data and documentation requirements during the first webinar. During the second offering, the technology team increased their involvement and effectively used technology resources to streamline the processes of registration through certifications.

For the second webinar offering, the lectures were all prerecorded and were made available in the Foundation's Facebook page for participant viewing several days before the live meeting. This gave the participants time to assimilate the webinar content, prepare their questions, and be more involved during the live session. The time for the live meeting was also changed to after dinner (8:00 PM to 9:00 PM) to accommodate the faculty and the participants who were working. At this time, data about COVID-19 have increased and there were more patient's experiences to base discussions on. It was decided that a real-life case scenario from the government COVID-19-designated hospital will be used to illustrate the needs and issues related to caring for a COVID-19 patient. Moreover, testimonies from different practitioners in the field were included in specified modules to highlight practices that can be adapted by the participants. The content of the webinars remained basically the same except for some updates due to increasing knowledge about the COVID pandemic and mandated government requirements such as mandatory wearing of face masks, face shields, and social distancing. At this time, the live meetings were also recorded and were made available, along with the videos of the lecture, in the TRF Facebook page for future reference and use.

During the live session of the webinar, discussion points were used to reiterate what was previously covered in the recorded lectures. Furthermore, in each of the webinars, an appropriate part of the case scenario was integrated and used to illustrate and discuss the issues in the care of the patient. In addition, testimonials from the actual frontliners gave the participants a glimpse of what is currently happening and the challenges in the care of COVID-19 patients.

Results

In both the offerings, comments and evaluation outcomes were very favorable[6] and many are looking forward to future offerings from the Foundation's HOPE program. Table 3 lists selected comments from both webinar groups. In most cases, the webinars went beyond the scheduled time and the amount of discussion and idea exchange was phenomenal; something the training team rarely experience during the face-to-face workshops. The second group of participants were especially vocal in sharing their local experiences since most of them work in both government and private hospitals in the Visayas region. The discussion sharing is particularly interesting since this region is composed of several islands that are separated from each other by bodies of water.

Table 3.

Participant comments

Webinar 1 Comments	Webinar 2 Comments
“Very timely, the topic really helps us to understand the situation better”	“Good to know on how to explore further in planning the care for the hospice patients. Thank you for this kind of topic”
“The COVID-19 pandemic has affected every aspect of our lives. We have to practice a “new normal” in order to carry on. Wearing mask, washing hands and physical distancing are the best weapon that we have on order to win this battle”	“That therapeutic communication is essential in communicating to patients on hospice care and those who have COVID. We should talk to them in simple, concise and perhaps on lay man’s term for them to understand their situation as well as in communicating to his/her family members”
On Communication: “Perfect topic for the present situation”	“Very timely seminar to understand palliative care during COVID-19”
“Most helpful: The “what-to-say” suggestions for communicating with patients, plus the additional anecdotes given by the speaker about real experiences”	“It was a very productive discussion. Thank you for sharing wonderful insights and expertise especially on use of various medications for treating the different symptoms. Your efforts are well appreciated. Mabuhay!”
“Most helpful: The discussion about the growing need for hospice and palliative care in the country, including the discussion on the DOH guidelines for the palliative care”	“Thank you for pushing us to re-learn about palliative care and making us realize its significant value in this difficult time. It will help if more time for Q and A is provided and when questions are answered by the subject matter expert real-time. Participant interaction done was a plus points. To the hardworking TRF Team, God bless [po] and keep up the good work. Keep safe”
“Good Quality Care at the end of Life – Though COVID-19 is a contagious illness, patients still deserve the utmost care from the healthcare workers and strong emotional support from the family members”	“Looking forward for the next session and thank you for such down-to-earth speakers… they really speak their minds and hearts. Thank you also for being so receptive with all the responses of the participants. I found that I really belong on how you always give importance to the inputs sent to you. Truly you are amazing”
“Palliative and supportive care is a very important aspect of the management of COVID, not only for the patient but also to the family and caregivers”	“I have always wanted to be a palliative specialist! This seminar is so enriching as I learned so much. Thank you

TRF: The Ruth Foundation; COVID-19: coronavirus disease 2019; DOH: Department of Health

Collaborative work between the technology and the training teams provided an avenue for mutual understanding of each other's roles, thus enhancing the working relationships between the teams. The efficient use of technology saved the training team hours of preparation prior to the event. Post webinar, automation of many forms greatly helped in organizing the documentation records and other logistical requirements.

Conclusions

The Foundation believes that altogether, these webinars were helpful in supporting the health-care providers at the time they need it most. It armed them with updated, evidence-based knowledge and skills that provided an extra layer of support as they continue to care for the unfortunate victims of the pandemic. Further, the health-care workers had an avenue to discuss cases and validate their care, not only with experts in the field but also with each other, thus creating self-assurance that they were providing the best of care under some unexplored circumstances. In turn, the team gained more experience in delivering learning materials using the wonders of technology, a learning curve for all that is more valuable in more ways than one. The Foundation hopes that the third COVID-19 webinar will be more efficient and will not focus on loss but in using palliative care concepts to maintain one's quality of life in the post-COVID era.

The whole experience of developing and executing these webinars made the training team realize that the challenges of COVID-19 mandate for social distancing can be efficiently resolved through technology and online delivery of training. In short, the training team is more than ready to undertake the Foundation's educational initiatives using different formats of delivery.

Financial support and sponsorship

The Ruth Foundation Leadership for Hospice Opportunity for Patient Empowerment (HOPE) Program.

Conflicts of interest

The corresponding author, Dr. Ayda G. Nambayan, is an editorial board member of Asia-Pacific Journal of Oncology Nursing. The article was subject to the journal's standard procedures, with peer review handled independently by Dr. Nambayan and their research groups.